First published in The Canberra Times

The withdrawal of the Australian Medical Association from a scheme to organise doctors for Aboriginal health in remote Australia is not of itself the world's greatest disaster, since it was not doing a fantastic job and was being properly criticised for it. But brave promises by Government, from the Prime Minister down, that something better will be organised can be taken with a grain of salt, as can any notion that somehow or other the market will sort out the problem. Recruiting doctors to work, even in country towns, outside major cities and regional centres has been a nightmare for years, with many of the schemes designed to fill the gap, including bonded medical scholarships, yet to show any results. But young doctors worried about working in a remote community with isolation, inadequate transport and communications, and a serious lack of professional support, facilities and comradeship, can hardly be blamed for understanding that their difficulties will be multiplied 100 times if they work in a predominantly Aboriginal community. Likewise with nurses, dentists and other allied health professionals, also vitally necessary if and this is a big if medical professionalism and medical technology are able to make much difference to the basic state of Aboriginal health.

Recruitment problems cannot be resolved merely by better salaries, by better accommodation and support inside communities, including far better arrangements for relief, peer support and upgrading training, important as all of these things are. Better-equipped workplaces might again make the job somewhat less difficult but, again, hardly strike at all of the frustration of trying to make a difference against a lot of odds. All the more so since there is so much that undermines idealism, job satisfaction and feeling of achieving anything. So much on the ground, but, equally, so much unnecessary nonsense from afar.

So many things one cannot control, including the casual bloody-mindedness of arbitrary decisions made thousands of miles away, the impatience and crankiness of officials with very little idea of what is going on, the tendency of every new decision maker (now the intervention taskforce) to think that nothing ever happened until they arrived on the scene. Add to that the perversity of people who seem, so often, to act against their own best interests, and the unease of working in a system presenting so many short-term emergency crises that it is difficult to live up to the ideal of focusing on things that might change things in the long term. Not to mention tiredness, jadedness, and the strain, despite any exhilaration, of living in an alien community with often corrosive and debilitating local politics and with almost no privacy. Such matters may not be in the job description, but anyone who investigates will find plenty to daunt.

Long ago, someone described the Aboriginal health industry as normally operating as though it were at the bottom of a cliff, at the top of which was a railway line with a bad curve. The trains going by the curve were continuously hurling victims down the cliff, to be patched up by the doctors down below. They were so busy doing it that no one had time to climb up and fix the railway line. Even when doctors find the work interesting or exciting, they feel besieged by the hopelessness of their task. Australian medicine has never much encouraged or supported doctors working in public health, and a great many doctors have almost been trained to think that choosing to work in such a field, on a salary, is a sign of second-ratedness. Australian heroes who largely conquered TB, polio, diphtheria, leprosy and a host of other public health problems over the 20th century with major campaigns did so without much credit from peers growing comfortable with the ailments of urban Australians. The development of some enthusiasm for doing something about Aboriginal ill-health from the early 1970s, and the charisma, idealism and challenge of a few leaders such as Fred Hollows and Peter Baume, inspired some young doctors into the field in the 1970s, and still does. But idealism, and the sense that one can make a real difference to people's lives, is often sorely tested by the practical realities, not least the frustration of coping with organisations seeming to have little idea of the real problems, little room for anything other than token consultation with those on the ground, and a tendency to assume that whatever those on the ground have been doing, they cannot, given the results, be doing it very effectively. The AMA, particularly through ophthalmologist Bill Glasson, contributed to this at early stages of the intervention by operating on a model of outside doctor as hero cavalry with magic pills, suddenly making everything better. Plenty of comfortable doctors, including specialists, were inspired to volunteer some of their time to visit communities, often with an organised media hailing their arrival. As often as not, such doctors shoved aside doctors and other health practitioners who had been in such communities for ages. Their participation, records and experience were not wanted, though the clinic was. In one case, the rude and peremptory leader of one team went outside to complain, by mobile, to AMA channels that the local people were being rude and peremptory to him. Shortly after, a senior federal health official rang the locals to threaten their funding.

Next day the team left, having issued an array of press statements hailing themselves and announcing that they had discovered a good deal of middle-ear disease. What a surprise. They had screened perhaps a half of the available children the intervention model of medical case finding is an absolute disgrace and, more likely than not, saw ones more, rather than less, inclined to be healthy. The epidemiological value of the ''findings'' was nil, though it will undoubtedly figure in new ''baselines'' being drawn up at taskforce central, as well as in impressive statistics showing how much work was done.

A good many of the heroic interveners, even the specialists, had very little knowledge or experience of routine conditions in the field. In due course, in a blizzard of further press statements and self-laudatory statements, some of the children seen were given ameliorative operations that will make little long-term difference to their problems. And the caravan, of course, has moved on, to further PR triumphs elsewhere. So far as I am aware, it will not be back, least of all to discover that it has probably done more harm than good. And that it has made some people whose work does actually count very annoyed.

On one occasion, a leading doctor associated with the intervention was briefed about arrangements for the follow-up surgery which had been arranged, and told it would be publicly announced next day. The shameless media hussy promptly arranged a national radio interview in which he criticised delays in organising them, knowing full well that the announcement the next day would then appear to be a response to his statement. No doubt he will, in due course, be given, along with other grandstanders of the intervention, an AO.

More than $100 million my guess is that it is more than $200 million once one throws in the logistical support has already been wasted on such exercises. The AMA has been much criticised, internally and from without, for extracting a premium from organising the fiasco, as well as its not very successful attempts to create a pool of long-term doctors willing to work in communities and cop such disrespect and contempt from the heroic holidaymakers. I'm not surprised the AMA has decided to vacate the field, and myself not very condemnatory of its charging a fee for finding and placing doctors. It would be nice, at least, if someone could do it, but letting the task again subside on the federal or local Health Department is unlikely to produce anything better, and certainly nothing cheaper. Health bureaucrats who were, admittedly, as horrified by the doctors' picnic as anyone else are simply unable to inspire potential health workers with the idea that a great and rewarding job is in the offing, particularly when one of the greatest disabilities of accepting such a job, whether in a government health bureaucracy or in an Aboriginal health bureaucracy, will be working with the health bureaucracy. Having someone other than the AMA involved might be useful in helping to address a crisis as great recruiting nurses and other health professionals but the whole process really would be better if it was managed by people who can give realistic information, help people understand what is involved, and show people just how interesting, absorbing and satisfying doing it can be. Even better, of course, would be some capacity to change things on the ground so that the work lived up to the job descriptions.

Jack Waterford is Editor-at-Large.